Baseline data set: Difference between revisions

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= <span class="mw-headline" id="Individuals_organisations_devices_and_locations">Individuals organisations devices and locations</span> =
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Most entries are attributed to patients, professionals, their organisations or services, locations or devices. In Discovery there is an attempt to uniquely identify these from the information provided, ideally using standard identifiers but in some cases deducing from names and context. In many cases these may be deduced only at the level of the sending systems by the use of internal identifier matching.
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== The patient or person demographic ==
 
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== <span class="mw-headline" id="The_patient_or_person_demographic">The patient or person demographic</span> ==
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Throughout the document the word “patient” is used to represent a person who is a user of the health or care service. (It is accepted that within the services themselves, service users may be referred to as patients, clients, service users or other terms)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This data covers the core demographics of the patient and their personal identifiers Whilst the table infers a one to one relationship, there is a one to many relationship between the patient and the related items in nearly all cases. For example the patient may change gender, change name, move home or acquire languages.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Note that in Discovery, a patient is considered as person in a role of patient (or client) in relation to ONE publisher.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>A person is identified as being linked to many patient demographic records. Thus a person is held independently of the patient resulting in a “master person” register<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient / Person<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>NHS Number The NHS number allocated to the patient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Name Name information and title for the patient. Ideally structured as “Family name”, “Given names” (in the correct order of presentation), “prefix” e.g. “Mr”, “Dr” and “suffix” e.g. “Junior”<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Administrative Gender Concept: The administrative Gender of the patient i.e. the gender that they consider themselves to be allocated to. May or not be the genetic or phenotypic gender<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Date of birth Date of birth of the patient, as far as is known<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Death indicator If a patient has died an indicator that they are now dead<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Date of Death If dead and if available, the date of death<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>PDS sensitive Flag to indicate whether the patient is marked as sensitive on the spine <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked items<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Address One or more entries including<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Qualified by Concept: address type (e.g. home address)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• The address of the patient relevant to the episode of care.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Status of the address<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• The date the address was valid from<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• The date the address was valid to<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contact potentially used in contacting the patient, each contact qualified by <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Concept&nbsp;: contact type e.g. home telephone, mobile, email <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Contact details e.g. email address or telephone number about the patient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Ethnicity Concept: Held in Discovery as an observation about the patient, indication as to the ethnic group the patient is part of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Language Concept&nbsp;: Held in Discovery as an observation about the patient, and qualified by whether the patient speaks the language or is their preferred language. May be several entries as language characteristics change<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked identifiers Identifiers – qualified by identifier type<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked relationships Linked relations
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== The practitioner in role ==
 
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== <span class="mw-headline" id="The_practitioner_in_role">The practitioner in role</span> ==
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This term refers to any person who provides care or is part of the health care process, excluding personally engaged or family carers. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span> A practitioner in role means a person providing care in the context of an organisation or service. The same person may have a number of roles across a number of organisations in which case it is expected that several entries may be created. This may be inferred by Discovery<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Practitioner<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Name Name information and title for the practitioner. Ideally structured as “Family name”, “Given names” (in the correct order of presentation), “prefix” e.g. “Mr”, “Dr” and “suffix” e.g. “Junior”<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Gender Concept&nbsp;: The administrative Gender of the practitioner i.e. the gender that they consider themselves to be allocated to. May or not be the genetic or phenotypic gender<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Date of birth Date of birth of the patient, as far as is known<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Address Qualified by concept&nbsp;: address type (e.g. work address)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>The address of the practitioner relevant to the role<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Active/ Inactive An indication of whether the practitioner is active in the role or not<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Service or organisation The service or organisation that the practitioner is operating in relation to a particular role<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Role type Concept&nbsp;: The type of role e.g. Doctor, nurse, receptionist, secretary that the practitioner operates as in this role<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Speciality Concept: The speciality of the practitioner (e.g. Cardiologist) <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contract period Start and end dates of contract with the organisation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked items<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contact potentially used in contacting the practitioner. Each contact qualified by <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Concept&nbsp;: contact type e.g. home telephone, mobile, email <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contact details e.g. address or telephone number about the patient to be <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Identifiers Identifiers qualified by identifier type and code
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== Family and kin Relationships ==
 
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== <span class="mw-headline" id="Family_and_kin_Relationships">Family and kin Relationships</span> ==
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Patients are related to other people via a variety of relationships, some of which may be genetic and others not. Relationships may also include carer relationships or next of kin.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Relationships (inherits attribution)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Related person information Information about the target person which may include Name, address, contact details<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Relationship type Concept: Relationship with source. May be a family relationship e.g. Father and may be qualified by genetic relationship. May be a relationship such as a carer or next of kin.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Status of relationship<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Related in Discovery Whether the related person is in Discovery or not<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Related patient Target may be a person in the Discovery Data service
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== Related person ==
 
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== <span class="mw-headline" id="Related_person">Related person</span> ==
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A related person may not be a patient in the Discovery service in which case the details of that person would be held independently<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Related person<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Name Name of related person<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Address Address of related person<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contact Contact details of related person<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Family and kin relationships Information about the patient and the relationship typ<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Identifiers Identifiers of the related person (e.g. NHS number)
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== Device ==
 
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== <span class="mw-headline" id="Device">Device</span> ==
</span></div>
In the context of Discovery a device is normally used to relate to the entry of a record or in relation to its use in a procedure or operation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Devices are categorised and full defined via the information model relationships. Thus each device represents an instance of a kind of device defined in the information model <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Device<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Device Name Device name<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>UDI human readable Human readable bar code identifier<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>UDI machine readable Machine readable bar code<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Manufacturer Manufacturer of device e.g. business organisation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Serial number Serial number of device<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Device type Concept: for the nature of the device e.g. cardiac pacemaker<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This may be at any level of granularity as the information model uses additional attributes to fully define the device<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Device version Version of the device (e.g. software version if the device is software)
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== Organisations departments and services ==
 
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== <span class="mw-headline" id="Organisations_departments_and_services">Organisations departments and services</span> ==
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In Discovery, these concepts are amalgamated into a single structure and the entities are differentiated via the category and the relationships with the other entities as described below. In many cases the relationships will be inferred by Discovery from the nature of the information transmitted. There is no expectation that publishers are required to populate the relationships.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation or service<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation identifier The nationally provided identifier or “ODS” code for the organisation or service if it exists<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Name Name of the organisation or service<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Address The address of the organisation or service<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contact details Main contact for the service itself e.g. main telephone number<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation/ service category Whether this is an organisation (e.g. Barts NHS Trust, Roya London Hospital) or a service e.g. Barts physiotherapy service or cardiology department<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>May be deduced when populating the organisational structures and relationships<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Speciality The speciality of the service e.g. Cardiology<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked Organisation A set of relationships between one organisational service entity and another each consisting of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• A relationship type such as “part of” or “provided by” e.g. Royal London Hospital is “part of”<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• A target organisation e.g. “Barts NHS Health Trust”<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Used to populate the organisational structures in the information model<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contacts Contact details for a person or team or department associated with the organisation consisting of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Name<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Contact details<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location Locations associated with the organisation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Identifiers Other organisational identifiers
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== Location ==
 
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== <span class="mw-headline" id="Location">Location</span> ==
</span></div>
Information about an actual location, building or entity that is related to the organisation that operates from it <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location identifier The nationally provided identifier for a location<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Name Name of the location<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Address The address of the organisation or service<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location Type Concept: Describes the location in the context of its purpose e.g. a ward or Branch surgery, a mobile MRI scanning unit. Note that the service may hold the information about what the location is used for rather than the location <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation A set of relationships between one organisational service and location consisting of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Contacts Contact details for a person or team or department associated with the location e,g, building maintenance, consisting of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Name<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Contact details
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== Team ==
 
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== <span class="mw-headline" id="Team">Team</span> ==
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Teams are named groups of individuals that are linked to one or more services<br/> Team<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Team name Name of the team<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation or services The services or organisations this team reports to<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Team members Practitioners that are part of the team
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= Health event subtypes =
 
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= <span class="mw-headline" id="Health_event_subtypes">Health event subtypes</span> =
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This section covers events that describe various health or care events, most but not all relating to a patient.
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== Patient event ==
 
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== <span class="mw-headline" id="Patient_event">Patient event</span> ==
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A patient event is a subtype of care event relating to a patient and usually recorded in the context of an encounter, a section within an encounter, or as part of another event<br/> Patient event (inherits health event)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Subject The patient to whom this event relates.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Note that a patient is considered as an individual person in the role of patient with respect of the organisation.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>There is no requirement to resolve common person identity in published data<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Part of An event that this event might be part of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Encounter An encounter that this event might be part of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>In section The section of the encounter that this event is placed in<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Part of problem The problem which this event may be linked to
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= Care process related events =
 
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= <span class="mw-headline" id="Care_process_related_events">Care process related events</span> =
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== Episode of care ==
 
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== <span class="mw-headline" id="Episode_of_care">Episode of care</span> ==
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A care episode is an association between a patient and a healthcare provider during which time care is provided. The association implies that the provider has some responsibility for the provision of care during the period of time covered by the episode.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>A care episode may be a concept that is explicitly stated. For example, GP registration is an explicit process by which the patient registers for care and in due course may be de-registered when they move elsewhere.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>A care episode may otherwise be deduced from the data provided , usually relating to encounters. For example the acceptance of a referral or the attendance at accident and emergency provide episode of care start points. Discharge from an outpatient clinical may be used to deduce the end of a care episode.<br/> Care Episode (inherits patient event)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Nature or type of episode A concept that describes the nature of the episode from a terminology set or ad-hoc information provided by publisher and mapped to a concept<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>May be inferred or derived from structured entry<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>For example, a GP regular GMS patient or a temporary resident<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Whether currently active (i.e. no end date) or inactive<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Initiating Referral A Link to the originating referral, whether self-referred, ambulance, GP referral etc. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>May be inferred from encounter information e.g. referral accepted, emergency admission<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Care episode Administration One or more links to care episode or registration administration processes that occur during the period of the care episode<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked Entries All encounters and many other entries may be linked to the care episode
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== General practice registration ==
 
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== <span class="mw-headline" id="General_practice_registration">General practice registration</span> ==
</span></div>
General practice does not consider their patients to be related to a particular episode of care. Thus a variation on care episode is designed for GP patients.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This deals with the administration of patient reception and registration in the context of General practice. This is particularly formal in respect of GP practice registration. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>General practice registration <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Status of registration or care episode processing<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>e.g. registration submitted, notification of registration, deduction received, deducted <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status sub-type Granular subtypes of the status e.g. “death”, “embarkation” or “armed forces” when patient is deducted<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient type Type of patient from the perspective of administration e.g. GMS patient, temporary resident
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== Encounter ==
 
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== <span class="mw-headline" id="Encounter">Encounter</span> ==
</span></div>
An encounter is an interaction between a patient and healthcare provider for the purpose of providing care, including assessment of care needs. Encounters are the mainstay of care provision and the concept covers encounters in any care domain. For example a GP consultation is an encounter and an in-patient stay is an encounter.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Encounters are often defined according to the publisher’s definition or even the nature of the IT system in use.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>In Discovery an encounter model is a superset of the different encounter models from the different domains and systems. The different patterns are differentiated by the use of Encounter types or archetypes.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>For example, a spell in hospital would be considered an encounter. The admission event is also considered an encounter, subsidiary to the spell encounter, as a discharge would be.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Similarly an accident and emergency attendance may have a subsidiary encounter for the initial assessment.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>The additional properties relating to encounter types (e.g. method of admission, critical care function type) etc, are considered as non-core and are referenced via the information model concepts. Each property type has a concept and each value class is considered concept. Consequently these are not specified in this document but are available via the ontology.<br/> Encounter: (inherits patient event)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Encounter Type The overall nature of the encounter mapped to the encounter type ontology<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Completion Status Concept: Status of encounter when this event is sent. It may be completed or ongoing or planne. In some systems encounters are created before they commence<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End Date/ time Date time encounter ended<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Duration In the absence of an explicit start and end time, the duration may be estimated<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Providing Organisation/ services or departments Additional department and/ or services that define the encounter more fully than the main organisation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>An entry may have a main organisation of Royal London, but the encounter may take place in the Royal London A<span class="mw_htmlentity">&</span>E department<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location Actual location of the encounter e.g. a physical building, wing , ward, or room or bed In most cases this may not be known (as the organisation itself implies a location)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>For example a branch surgery of a GP practice or bed 1, Ward 10 <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked appointment The appointment to which the encounter may be related<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Subsidiary of An encounter that the encounter may be part of or sub<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked care episode The care episode the encounter is linked to.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Additional Practitioners Additional practitioners other than the main attributed practitioner involved in the encounter
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== Context Headings or sections in encounters ==
 
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== <span class="mw-headline" id="Context_Headings_or_sections_in_encounters">Context Headings or sections in encounters</span> ==
</span></div>
A heading is grouping construct that segregates clinical entries within an encounter, episode or a document such as a care plan for establishing human inferred context. Their presence is primarily for the purpose of display and context inference and represent the headings entered via a clinical or care planning system e.g. a form template or consultation.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>As a heading is a simple text structure label there is no requirement for attribution as it is assumed that attribution is shared with the parent encounter<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Section<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Heading type Concept: for the heading<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>e.g.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Clinician entry/ Examination/ CVS Examination<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>CDS Entry/ Primary Diagnosis<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Clinician entry/ Past procedures<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Parent heading Link to the parent heading<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Order Order of heading in relation to its parent for display purposes<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked encounter The encounter that contains the heading
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== Referral Request or procedure request ==
 
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== <span class="mw-headline" id="Referral_Request_or_procedure_request">Referral Request or procedure request</span> ==
</span></div>
A referral request or (procedure request) includes request for advice or invitation to participate in care and is not limited to conventional referrals. A referral request often precedes the encounter or care transfer that occurs subsequently. Furthermore a referral request may accompany a care transfer e.g. a request for input from a community health professional during the discharge process. The referral type is considered as the core observation concept <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Referral inherits attribution<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Referral request &nbsp;: inherits patient event<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Priority Concept: Priority of referral request<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Referred by type Concept: The type of source the transfer originated as e.g. self referral, healthcare professional referral<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Source organisation Sender service or organisation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Speciality requested Concept: the speciality of the referral request<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Procedure or Service type requested Concept: If available, the nature of the service requested e.g. Nephrology, chest xray<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Request Reason e.g. The clinical condition or problem that is reason for referral<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Recipient service or organisation The referral recipient organisation or service e.g. hospital or department<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Recipient location Location of the recipient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Recipient practitioner If referred to a person, the practitioner<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Referral UBRN Unique referral booking number<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Referral mode Concept: Means of referral e.g. Verbal, written, ERS<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked episode Linked care episode for which this is the originating referrals
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== Appointment session ==
 
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== <span class="mw-headline" id="Appointment_session">Appointment session</span> ==
</span></div>
An appointment session is an appointment grouping implying a session or a clinic, which incorporates a number of appointments<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>In the Discovery model, all appointments are linked to a schedule (whether a schedule pre-authored or not) i.e. a standalone appointment would have one schedule for the stand alone appointment<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment schedule&nbsp;: inherits attribution<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Organisation or service Organisation or service responsible for this schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Location Location for the schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Schedule type Concept: for the type of schedule e.g. diabetic review<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Schedule description Textual description of the schedule e.g. Dr Jone’s acupuncture clinic<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Speciality Speciality associated with the schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Start date/ time Planned start date/ time of schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End date/time End date time of schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked appointment slots Linked appointments to the schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Practitioners Practitioners linked to this schedule
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== Appointment ==
 
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== <span class="mw-headline" id="Appointment">Appointment</span> ==
</span></div>
This is information about a particular appointment or slot as planned. The slot creation shares attribution with the schedule<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment category Concept: describing what type of appointment in terms of routine, urgent etc<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Planned Reason Concept: of reason for appointment from the appointment planning perspective <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Description Any text description for the appointment slot<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Start time Start date and time of slot<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End time End date and time of slot<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Planned duration Planned duration of appointment (may or may not be timed)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient Patient booked into the slot<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Slot booking status Whether booked, reserved, free<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Attendance status Whether the patient arrived, sent for, left<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Booking urgency Indication as to whether it was booked as an urgent appointment (whether the appointment was marked as urgent or not<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Interaction type Whether face to face, telephone, skype etc<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked schedule Links to the schedule containing the appointment<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Booking history<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span> Links to booking history including<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Booked&nbsp;:cancelled<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Date and Time of booking<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Attendance history Links to the attendance status history
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== Appointment booking history ==
 
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== <span class="mw-headline" id="Appointment_booking_history">Appointment booking history</span> ==
</span></div>
Information about booking and unbooking of an actual appointment prior to the patient attending<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Date and time of booking and by whom are attributed in attribution fields.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>The latest entry represents the information prior to the patient arriving or appointment attendance<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment booking: inherits attribution<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Booking or cancellation Whether this is a booking or a cancellation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient Patient booked into slot<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Booking urgency Whether the appointment was urgent (whether or not reserved as an urgent slot)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient related reason Reason for appointment from patient’s perspective (i.e. if booked)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Interaction type The actual interaction type when booked (e.g. telephone)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment slot Link to the appointment slot
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== Appointment attendance history ==
 
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== <span class="mw-headline" id="Appointment_attendance_history">Appointment attendance history</span> ==
</span></div>
Historical Information about an actual attendance for a patient for an appointment i.e. after the patient has arrived for appointment<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment attendance history<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Concept: the status e.g. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Patient Patient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>start time The actual start time of this status<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>end time The actual end time of this status<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Actual duration The actual duration of the appointment<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Actual interaction type Nature of the actual interaction<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Appointment slot Links to the appointment slot
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== Care plan ==
 
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== <span class="mw-headline" id="Care_plan">Care plan</span> ==
</span></div>
In the context of Discovery a care plan is a relatively simple data subset of a complex document structure for the purposes of tracking and analysis. There is no attempt to precisely define a care plan beyond the simple data items listed here<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Care plan &nbsp;: inherits attribution<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Document Status Whether the plan is draft, active, no longer active<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Type of plan Concept: for the type of care plan. For example, Asthma action plan, Cancer management plan<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Description Description of plan<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Time period The start and end date or period of the plan (the start date may precede the effective date)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked Headings Heading categorised, Activities, goals targets, observations linked to the plan<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked episodes Care episodes linked to the plan<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Parent plan Care plans this plan is part of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Associated practitioners Additional practitioners or teams associated with the plan<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Associated teams Links to teams associated with plan <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked activities Links to care activities<br/> <br/> Care plan activities<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>These are modelled as observation types such as <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Activity<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Goal<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Target 
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= Clinical health events =
 
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= <span class="mw-headline" id="Clinical_health_events">Clinical health events</span> =
</span></div>
This section covers data about the patient that is generally considered “clinical” either observed characteristics of the patient or clinical procedures or measurements that have been carried out.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>In the Discovery model clinical data is modelled around observations i.e. different types of clinical characteristics inherit from simple observations.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Care records are usually structured according to a series of sections or “headings” a standard having been established by the PRSB. This enables records to be viewed as documents although the headings have no inherent meaning in themselves.
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== Observation ==
 
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== <span class="mw-headline" id="Observation">Observation</span> ==
</span></div>
An observation is considered a type of health event that records some characteristic of the patient or some procedure performed on the patient, excluding the specialised events such as medication.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>An observation in Discovery is much broader than an observation in FHIR. Because observations may be highly specialised, like encounters, only the generic properties are illustrated in this document. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>The type of observation is deduced from the observation concept itself. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observations may be linked at any level of nesting. In particular, tests and concept results observations are considered as 2 separate but linked observations, one for the test, the other for the result. This varies the Discovery observation model from the FHIR model that includes both test and result in the same observation.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>For example, a blood pressure would be modelled as 3 observations as follows:<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observation 1 Blood pressure<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observation 2 Systolic blood pressure value= 120, part of observation 1<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observation 3 Diastolic blood pressure value= 80, part of observation 2
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== Simple observation ==
 
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== <span class="mw-headline" id="Simple_observation">Simple observation</span> ==
</span></div>
A simple observation is the root for most clinical entries about a patient, ranging from a piece of text or codeable concept including an advanced Snomed expression. Observations may be specialised by purpose (e.g. observation, target, goal, aim, Various specialised observations such as allergies, numeric values, family history, immunisations, reports, documents and referrals extend the simple observation mode <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observations can be standalone or exist within a collection of observations with a parent observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Simple Observation&nbsp;: inherits patient event<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observation type Concept: Nature of the observation, including whether this is a sub-type entry (described elsewhere) or categorisation within the observation type itself e.g. sign, symptom, aim, target, goal , test header, or specialist type e.g. blood pressure. Equivalent to an archetype<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>It is inferred by the code within the observation, however it is modelled separately as it drives business logic<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Prompt Text representing a prompt on a form to which the observation represents the nature of the response to the prompt<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This should not be confused with a parent observation such as a test order which has this observation as a test result,<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Description Text entry for the observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Is problem Whether the observation is part of the problem definition<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Problem episode Concept: Whether the observation is new or a review of a problem or other specialist episode e.g. flare, evolved from<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Normality A flag indicating whether the observation is marked as abormal (e.g. ABN, HI,LOQ)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked problems The problems the observation may be linked to including<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Concept&nbsp;: Nature of link e.g. evolved from<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Problem <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Flag Any flags associated with the entry
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=== Numeric observation ===
 
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=== <span class="mw-headline" id="Numeric_observation">Numeric observation</span> ===
</span></div>
One of the commonest observations are pathology results and they often have numeric values as results. They extend simple observations<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Numeric Observation&nbsp;: inherits simple observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Operator Operator associated with the value e.g. <span class="mw_htmlentity"><</span> or <span class="mw_htmlentity">></span> or =Value Numeric value of result <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Range (s) List of qualified range each consisting of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Range qualifier (e.g. normal, normal for males)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Lower limit<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Upper limit<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Units Concept&nbsp;: Units of measurements
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=== Date time observation ===
 
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=== <span class="mw-headline" id="Date_time_observation">Date time observation</span> ===
</span></div>
A less common observation is one where the result value is a date.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Numeric Observation&nbsp;: inherits simple observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Result date Date time of the observation eg. Expected date of delivery or date of last period.
<div><span id="<@@@BTAG110453@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
=== Procedure ===
 
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=== <span class="mw-headline" id="Procedure">Procedure</span> ===
</span></div>  
Procedure provides more information beyond a simple observation about an operation or observation relating to the outcome of the procedure.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Within Discovery, unlike FHIR a complex procedure description (that includes body site, laterality, method and nature of device) is represented by a Snomed expression in the observation concept. <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Procedure: inherits simple observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Performed period Period of time the procedure took<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End time Date and Time procedure ended <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Outcome Concept: Outcome of procedure<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Complications Links to complication observation entries<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Follow ups Links to care plan follow up entries<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked problems Links to the observation reasons for procedure<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Devices used List of devices used in the procedure qualified by “main device” or “used device”
<div><span id="<@@@BTAG199278@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
=== Allergy, intolerance and adverse reaction ===
 
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=== <span class="mw-headline" id="Allergy.2C_intolerance_and_adverse_reaction">Allergy, intolerance and adverse reaction</span> ===
</span></div>
Allergies, intolerances and adverse substance reactions are grouped together and are extensions of simple observations whereby the simple observation code includes the full concept of the allergy e.g. “allergy to penicillin”<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>The additional data relates to more specific information about the substance and reaction.<br/> Allergy&nbsp;: inherits simple observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Whether active or inactive<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End date Date allergy became inactive<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Substance Concept: indicating the substance that created the adverse reaction or allergy<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Manifestation Concept: indicating the nature of the reaction e.g. rash, anaphylactic shock<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Manifestation description More detail about the manifestation <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Severity Severity of the reaction or allergy<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Observations Observations associated with the allergic reaction
<div><span id="<@@@BTAG150593@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
=== Immunisation ===
 
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=== <span class="mw-headline" id="Immunisation">Immunisation</span> ===
</span></div>
Immunisation extends a simple observation by providing more information about the immunisation procedure and vaccine used.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This is a summary of immunisation, (expected to be extended)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Immunisation&nbsp;: inherits simple observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<br/> Manufacturer Manufacturer of vaccine<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Batch number Batch number of vaccine<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Expiry date Expiry data of vaccine<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Vaccine product Concept: of the actual vaccine product<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Dose sequence Number within a sequence (may be deduced)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Doses required Number of recommended doses in series<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Reaction Link to observation describing reaction to immunisation 
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== Problem ==
 
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== <span class="mw-headline" id="Problem">Problem</span> ==
</span></div>
Problem is a patient and record management construct designed to help manage care. The main purposes of problem structures are to highlight significant issues and to group entries in the record to enable a narrative view categorised by a focus of care. In different care domains different terms are used such as “problem”, “issue” or “need” but from a structural perspective they are the same.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>A problem is always associated with at least one observation and therefore automatically shares its attribution.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Problem<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Problem type Concept: for the term that the healthcare worker assigns to this construct e.g. Problem. Issue, need<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Terminological construct for the status, whether active inactive, dormant<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End Date Time Date and time problem ended<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Significance Significance assigned to the problem by a user. May be inferred from a knowledge base<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Anticipated duration Whether likely to be temporary permanent, or duration<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Parent problem A problem that this is a child of<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Defining observations<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span> Observations that form the title of the problem<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked entries Entries in the care record linked to this problem, e.g. encounters, observations` 
<div><span id="<@@@BTAG184285@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
== Medication statement ==
 
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== <span class="mw-headline" id="Medication_statement">Medication statement</span> ==
</span></div>
Medication statement entries are templates for describing and authorising a course of medication or an intention to prescribe. Medication entries are precursors to the prescribing of a drug (medication order), dispensing of a drug (e.g. chemist) or the administration of a drug (e.g. medicine administration by nurse).<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>In General practice, acute prescriptions are based on medication entries with a single authorisation and repeat medications are based on medication entries with multiple authorisations. In hospital, the drug chart contains the medications.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication statement: inherits patient event<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Whether active or past (inactive)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication Concept: for the drug or appliance.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This may be an actual medicinal product, a virtual medicinal product or a virtual therapeutic moiety<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Dosage May be a free text dosage (one three times a day, or a structured dose concept including:<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration times e.g. 10 am 6 pm)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Either<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration quantity e.g. 2<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration units e.g. capsules<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>And.or<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• drug quantity per administration e.g. 250<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• drug quantity units e.g. mg<br/> Order Quantity – number of units Quantity and units For the ensuing prescription order Number of tablets or capsules for the course e.g. 28, 1 <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Course type Whether a repeat, acute , automatic repeat, repeat dispensing<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Number repeats authorised Number of prescriptions authorised as a repeat before medication review required e.g. 6<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication review Review date for this particular medication<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Prescription duration Anticipated Duration of each prescription e.g. 28<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Prescription duration units Duration units for prescription e.g. days<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Additional instructions Additional instructions to the patient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Pharmacy instructions Additional instructions to the pharmacist<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Order in heading Order within the heading in encounter<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Management authority Nature of the domain organisation that manages the administration of this medication e.g. hospital only<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Originated by Domain type that originated this medication e.g. Hospital<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Reason for ending Textual or concept reason the medication was ended <span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>End date time Date and time medication was ended<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links
<div><span id="<@@@BTAG193714@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
== Medication order ==
 
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== <span class="mw-headline" id="Medication_order">Medication order</span> ==
</span></div>
A medication order is the actual prescription for a medication item. It represents the instance of the order derived from the medication statement. It inherits MOST fields from medication and has some additional items. However, field values for the order may be different from the field values of the medication statement so they are repeated for clarity<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication order&nbsp;: inherits patient event<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Heading Context heading for entry<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Whether active or past (inactive)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication Concept: for the drug or appliance.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>This may be an actual medicinal product (e.g. Ventolin HFA 200 mcg inhaler), a virtual medicinal product (e.g. a generic - salbutamol 200 mg inhaler) or a virtual therapeutic moiety (e.g. salbutamol 200 mg inhalation)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Dosage May be a free text dosage (one three times a day)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>or a structured dose concept including:<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration times e.g. 10 am 6 pm)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Either<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration quantity e.g. 2<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• administration units e.g. capsules<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>And.or<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• drug quantity per administration e.g. 250<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• drug quantity units e.g. mg<br/> Order Quantity – number of units For the ensuing prescription order Number of tablets or capsules for the course e.g. 28, 1<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Order Quantity- units Unit concept for course e.g. (28)- capsules, (1) inhaler<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Course type Whether a repeat, acute , automatic repeat, repeat dispensing<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Number from authorised count Number of the prescription as compared to the authorised number in the linked medication (e.g. 2/6)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Prescription duration Anticipated Duration of each prescription e.g. 28<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Prescription duration units Duration units for prescription e.g. days<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Additional instructions Additional instructions to the patient<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Pharmacy instructions Additional instructions to the pharmacist<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Order in heading Order within the heading in encounter if noted in the encounter<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links
<div><span id="<@@@BTAG196740@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
== Document ==
 
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== <span class="mw-headline" id="Document">Document</span> ==
</span></div>
Used to provide the content of a document A medication order is the actual prescription for a medication item. It represents the instance of the order derived from the medication statement. It inherits MOST fields from medication and has some additional items. However, field values for the order may be different from the field values of the medication statement so they are repeated for clarity<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Medication&nbsp;: inherits attribution<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Document Type Concept or Text: Type of document<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Document content Text representation of content<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Encounter Encounter linked to this observation<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Heading The heading in which the observation took place<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked medication Links to medication that was used as the template
<div><span id="<@@@BTAG191862@@@>" class="mceNonEditable wikimagic mw-tag mceNonEditableOverlay mwspan" title="
== Flag ==
 
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== <span class="mw-headline" id="Flag">Flag</span> ==
</span></div>
A flag is a warning or notification of some sort presented to the user - who may be a clinician or some other person involve in patient care. It usually represents something of sufficient significance to be warrant a special display of some sort - rather than just a note in an entry<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Flag<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Field Description<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Status Status of flag (active, inactive)<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Flag category Concept: Nature of flag for example<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Flags related to the subject's dietary needs.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>• Flags related to the patient's medications.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Used in business logic to determine when the flag is displayed<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Flag type Concept: to describe the flag e.g.<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Do not stop taking this medication without professional advice<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Text Alert text<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Links<span class="single_linebreak" title="single linebreak"><mwspan>¶</mwspan></span>Linked entry Entry to which the alert relates
 
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Revision as of 06:38, 1 May 2020

Discovery Data Service contains health and care-related data.

These articles describe the nature of the types of data processed by the data service. 

In addition to reading these articles, the reader can visit the information model viewer at [x] which enables the entire information model to be explored, including the ontology, the data model, and the various code sets and data sets that have been developed.

Overview

Each main data type is called an entity. 

The entities described here are derived from health records. A health record consists of a set of "entries", each entry describing either an event that has occurred, an event that might occur, or a state. In addition, entries contain references to external things, often organised into Directories. Thus an entity is either a type of entry or a type of thing that the entry refers to.

The approach to categorising the data types has been heavily influenced by HL7 FHIR. In this approach, entries are roughly categorised according to the type of business process that the entry describes.

Within the full Discovery information model, entity types are semantically defined in an ontology, and the data model supports unlimited but ontologically controlled extensibility. This provides the potential for holding data at any granular level of specialisation.

Only the broad categories are described here, for the purposes of information. The information model itself describes the extent of properties and their values that are supported at a particular point in time.
 

Generic entities

This section deals with entities that are relevant to all parts of the model.

Provenance

Discovery tracks data throughout the pipeline including the receipt of the data and the transformation of the data.
Discovery also retains any provenance related information relating to the item as is was originally recorded in the publisher system, including any provenance information that the publisher may have.
Discovery itself, broadly speaking, follows the W3C PROV standard in that it records Entities, activities and agents and any number of relationships between them based on sub-properties of the main W3C provenance relationships.

 

Provenance.jpg

 

The main entity types and main properties are listed here:

Provenance entity

This is a reference to a stored item of data which is of sufficient importance to require a record of provenance. The data may be a record entry, or in the case of a deleted record, the previous entry. In addition, it may point to messages or files that were stored or created as part of the processing of health data.

Property Description
Entity type The type of entity that is the provenance of 
Entity location The actual location of the entity which may be a database ID or URL

 

 

 

 

 

 

Provenance activity

In order to have generated some data, or changed some data, or deleted some data, some form of activity has taken place. This entity holds the nature of the activity that took place and the date and time it took place. Provenance can be illustrated by providing a timeline of all linked activities, operating as a chain going back in time.

Property Description
Activity type The type of activity
Start time The date and time the activity started
End time The date and time the activity ended

 

 

 

 

 

Provenance agent

This is a person or thing that performed an activity, or is responsible for an entity. Agents operate in the context of roles, which are represented as properties of the relationship between the agent and the activity.

Property Description
Agent type The type of agent involved
Agent identifier The identifier of the agent which might be a DBID or URL

 

   

 

 

Main Provenance relationships

This is a high-level listing of the types of relationships between the provenance objects. An ontology of relationships can be viewed in the information model viewer

Relationship Description
Derived from Links an entity to another entity from which it was derived
Generated by Links an entity to the activity that generated it
Attributed to Links an entity to an agent that the entity is attributed to e.g. the author or owner
Was associated with Links an activity to the agent that it was associated with, e.g. who performed it, including the role the agent was performing in
Acted on behalf of Links an agent to the organisation (or other agent) that an agent acted on behalf of

 

 

 

 

 

 

 

 

Health Event

A health event is an abstract class referring to an entry that represents something that has happened, or may happen, at a point in time, or over a period of time, related to the health or care or a person.